Weekly Progress Note and Planning Form

Student Name: Harrison Ogle Clinical Site: Ohio Health Rehab Hospital PT 9003 Date: 10/5/2023

To be filled out by student prior to meeting

Were the prior weekly goals met? Yes X Ongoing ___No __N/A

Comments: I was able to complete a few daily treatment notes by the time I went to get my next
patient, however, more often than not I have 90% of the note done and will just have the summary to
complete. Overall, my documentation efficiency has significantly improved and I am able to get daily
treatment notes, weekly progress notes, initial evaluations, and discharge notes done in a timely
manner. I continue to improve upon my ability to document at the point of care while still providing
quality physical therapy services for each of the patient’s I see. I was able to get all weekly notes done
prior to the start of the day on Wednesday. The quality and conciseness of my documentation has
improved with minimal errors noted. I continue to lead the PT of our team conferences and I am still
engaging with nursing and other healthcare professionals with each of my patients.

The most important thing I learned this week: Vitals truly are vital. Patient’s medical statuses can change
in the blink of an eye and it is important that we are monitoring vitals especially when patient’s
demonstrate changes in presentation or their functional mobility suddenly changes. It is important that
we not only immediately address these situations, but report them to nursing and the physicians so they
are aware. I think it is important that we are prepared and ready for the worst situations so we may act
promptly and efficiently when the time arises. Unfortunately, sometimes all we can do is initiate care
and call a code as needed. This past week I had evaluated a patient who coded the following day while
transferring with OT, his room empty a few hours later. This sort of grounded me and brought me back
to the reality that something like this can happen in the inpatient setting even if patients are “medically
stable”. As a result of the situation, I feel that I am paying better attention to slight changes in patient’s
presentation and monitoring vitals when appropriate. This helps give me peace of mind knowing that I
am doing what I can to help keep my patient’s safe.

One thing I’m doing very well: My conciseness and timeliness with documentation has really improved
over the last week. I am doing a better job of finding a balance between documenting while still
providing quality patient care. I am getting a majority of my daily notes done during the session and am
only having to add a few details here and there or complete the summary. I have done a better job of
documenting during initial evaluations whether they are 90 minutes or 45 minutes long. While my
documentation efficiency can still improve, I feel that I have made some big jumps in progress over this
past week.

Area(s) identified for growth: I think continuing to work on my documentation as stated multiple times is
my biggest area for improvement. I also think I could review more neuroanatomy and physiology just to
help bolster my understanding and allow me to come up with better targeted exercises and
interventions.

I would like to get ___MORE ___ LESS or the X SAME amount of feedback from my CI.

Kudos/Feedback for CI: Jill I do a great job of communicating throughout the day about patients, my
performance, and how things are going overall. I feel that we are always on the same page about things
and we address things as they present themselves. Her feedback is always timely, constructive, and
respectful which creates a great student – CI relationship and open communication. Jill makes sure that
even when census is low or she has other administrative things to do that I am still treating and seeing
patients with other CI’s. She makes it a priority to maximize my learning experience and provides me
unique opportunities that other places cannot provide. She has been a great CI to learn from!

Goals for next week:

1. Discuss professional growth opportunities, continuing education, and conferences/networking

that can be beneficial for new clinicians.
2. Complete all morning daily treatments notes before 1 pm.
3.
4.
5.

To be filled out by clinical instructor: please see definitions below

Safety: __WB __B __FP __AP __A

Follows health and safety precautions, takes appropriate steps to minimize risk of injury to patient, self, and others.

Professional Behavior: __WB __B __FP __AP __A

Demonstrates professional behavior during interactions with others; accepts feedback without defensiveness; maintains productive working
relationships with others; punctual with arrival times, documentation, and other assignments; recognizes and maximizes opportunities for
learning; implements feedback; utilizes available resources for problem-solving; demonstrates teamwork and flexibility.

Communication: __WB __B __FP __AP __A

Student appropriately communicates in writing, verbally, and non-verbally with CI, peers (all healthcare providers), patients, caregivers, and
family members and appropriately interprets verbal and non-verbal communication from others; demonstrates active listening during
interactions with CI, peers, patients, caregivers, and family members; appropriately seeks feedback.

Critical thinking: __WB __B __FP __AP __A

Presents a logical rational for clinical decisions; utilizes information from multiple data sources to make clinical decisions (eg, patient,
caregivers, health care professionals, medical records); recognizes when plan of care and interventions are ineffective; identifies areas needing
modification and implements changes; demonstrates an ability to make clinical decisions in ambiguous situations; assesses patient response to
interventions using credible measures.

**Caseload:
____ % Overall ___% Familiar ___ % Complex

Kudos/Feedback for Student:

CI Comments for DCE:
□ Significant Concerns / Return Phone Call Requested

Student Signature _________________________ CI Signature ___________________________

**Caseload percentages: Overall caseload is % as compared to competent clinician new graduate

physical therapist at your clinical site. The % familiar and % complex is the number of patients the
student is seeing that are familiar versus complex. For example, a student may have a 20% overall
caseload. This caseload may consist of 90% familiar patients and 10% complex patients.
90% Familiar 10% Complex 20% overall
Rating Rating Scale Definitions
Well Below (WB) Student requires Guidance from their clinical instructor to complete an item for all patients.
Guidance: the student is dependent on the CI to direct all steps of the evaluation, treatment, and clinical decisions
Below (B) Student requires supervision and/or has difficulty with time management while completing the item for all patients.
The student could continue to require Guidance for the patient with a more complex presentation while only needing
Supervision with the patient with a familiar presentation.
Supervision: the student can carry out evaluation and treatment, but CI is needed to provide verbal cueing to
facilitate decision making, correct minor errors, and monitors for efficiency and/or effectiveness.
At that Level for Student is independently managing patients with a familiar presentation; they are at the level of a competent clinician
Familiar Patients with these patients when performing an item. Students require Supervision to manage patients with a complex
(FP) presentation and they are below the level of a competent clinician for these patients.
Supervision: the student can carry out evaluation and treatment, but CI is needed to provide verbal cueing to
facilitate decision making, correct minor errors, and monitors for efficiency and/or effectiveness.
At that Level for Student is independently managing both patients with a familiar presentation and patients with a complex
All Patients (AP) presentation. Student can carry an appropriate caseload for your clinic and achieve an effective outcome with
patients. The student is at the level of a competent clinician in your setting.
Above (A) Student is performing above the level of a competent clinician in your clinic. Clinical skills are highly effective and
demonstrate the most current evidence in practice. The student can carry a higher-than-expected caseload. The
student actively seeks out and develops independent learning opportunities. The student serves as a mentor to other
students and provides resources to the clinical staff.
From Clinical Internship Evaluation Tool (CIET) Rating Definitions

Types of Patients:

 Familiar presentation: Could include any of the following: a patient diagnosis/problem that is seen
frequently in your setting, a patient with a diagnosis that the student has evaluated and treated more
than once, a diagnosis that was specifically covered in the student’s didactic curriculum, a patient who
does not have a complex medical history or complicated course of care for this episode of care in physical
therapy.

 Complex presentation: Could include a patient problem/diagnosis that is rarely seen, a patient
problem/diagnosis that the student did not cover in their didactic curriculum, a patient diagnosis that is
rarely seen in this clinic, or the patient who has had a complicated course of care for the present episode
of care or a complex medical history.